Passpoint Quality Improvement Block 3 MS ML6

The nurse-manager is developing a "read-back" procedure to reduce medication administration errors. What is the purpose of the "read-back" requirement? Select all that apply. A. to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information B. to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information C. to prohibit prescriptions and test results from being communicated verbally or by telephone D. to encourage the use of electronic medical records E. to minimize the risk for nonauthorized personnel from giving prescriptions that are communicated verbally or by telephone

A, B A National Patient Safety Goal of the Joint Commission is to improve the effectiveness of communication among caregivers. The requirement for verbal or telephone prescriptions, or for telephonic reporting of critical test results, is to verify the complete prescription or test result by having the person receiving the information record and "read back" the complete prescription or test result. Effective communication that is timely, accurate, complete, unambiguous, and understood by the recipient reduces error and results in improved client safety. "Read-back" procedures are not intended to discourage or prohibit telephone communications among health care providers (HCPs) or to promote the use of electronic medical records. Safety procedures, such as provider identification codes, are in place for HCPs to give verbal or telephone prescriptions.

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. A. to make data entry into a computerized health record easier B. to prevent medication errors C. to make it easier for clients to understand the medication prescriptions D. to ensure efficient and accurate communication E. to ensure client safety

B, D, E Abbreviations can be misinterpreted, and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.

The nurse notes that several assigned clients are developing signs of pressure injuries. Which action should the nurse take first? A. Plan for every client to be repositioned every 2 hours while awake. B. Speak to the nurse who cared for the clients the previous day. C. Formally report the findings related to the ulcers to the nurse manager. D. Investigate the potential causes for the clients' pressure injuries.

C When a quality of care issue is identified, it should be reported through the chain of command. Informing the nurse manager of the finding is the first action to take. The nurse manager would initiate an investigation, including a review of medical records, to determine the potential cause for the pressure injuries. While the nurse should plan and implement actions to reduce the risk of further pressure injury development, this would not be the first action to take. Pressure ulcers take time to develop, and the nurse should not assume the care delivered the prior day is the primary issue.

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report? A. Telemedicine report. B. Nurse's shift report. C. Transfer report. D. Incident report.

D An incident report, also termed a variance report or occurrence report, is a tool healthcare agencies use to document anything out of the ordinary that results in or has the potential to result in harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns and initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link healthcare professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

A 3-year-old with dehydration has vomited 3 times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 48.5 lb (22 kg), has a normal saline lock in their right hand, and has had 30 mL of urine output in the last 4 hours. Using the situation-background-assessment-recommendation (SBAR) technique for communication, the nurse calls the health care provider with the recommendation for which prescription? A. beginning an intravenous (IV) antibiotic B. establishing an indwelling catheter C. giving a dose of loperamide D. starting a fluid bolus of normal saline

D The child is dehydrated, is not able to retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance of IV fluids. Antidiarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses. Maintaining strict intake and output is important in all children with gastroenteritis.

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse meets with the team to develop a change strategy based on indicators. Which statement by a team member shows a need for further teaching regarding performance management? A. "We can collaborate with staff from the ED and the ICU to formulate strategies and implement change." B. "We can review ED staffing to see if shortages affect ICU admission." C. "We can use statistics gathered in the ED during triage to determine the average time for admission to the ICU." D. "We can discipline the ED staff for not getting the clients to the ICU fast enough."

D Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.

A primary unit nurse tells the nurse-manager that a registered nurse hired 6 weeks ago needs an additional week of orientation to function effectively on the staff. Which action is mostappropriate for the nurse-manager to take? A. Meet with the new nurse and the primary nurse and help set up an additional week of orientation. B. Explain to the primary nurse that a 6-week orientation is standard. C. Meet with the new nurse and question the new nurse about deficits in performance. D. Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process.

A The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation does not mean that a nurse is not competent or that there are deficits in performance. Although a 6-week orientation may be standard, orientation periods should be individualized to meet the needs of the staff as well as provide the best client outcomes. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete the orientation as efficiently as possible.

The nurse is instituting a falls prevention program. Which personnel should be involved in the program? Select all that apply. A. registered nurses B. family members C. insurance providers D. unlicensed assistive personnel E. client F. housekeeping services

A, B, D, E, F Client safety is a priority for the client, the client's family, and all of the personnel working on this unit. All of these persons must be engaged in using strategies to prevent falls. The insurance provider does not need to be involved in developing a falls program.

A nurse is working as part of team on the unit on a performance improvement initiative to address a concern that clients are not receiving adequate preoperative teaching. Now that the problem has been identified, which action would the nurse do next? A. Meet with the parties involved to develop a strategy. B. Implement the necessary change for the problem. C. Identify the person responsible for the problem. D. Revise the focus of the strategy.

A Performance improvement involves four steps: discover a problem (which has already been identified); plan a strategy using indicators based on a meeting with the parties involved; implement a change; and last, assess the change, and if the outcome is not met, plan a new strategy or refocus the strategy to effect change.

The nurse-manager on the oncology unit wants to improve documentation of the effectiveness of analgesic medication within 30 minutes after administration. What should the nurse-manager do first? A. Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts. B. Consult the pharmacist. C. Change the policy of documentation to 45 minutes. D. Consult the nurses on the evening shift where documentation of analgesia is the greatest problem.

A To determine the cause of this problem, a quality improvement study should be conducted along with a chart audit. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Changing the time to chart from 30 minutes to 45 minutes does not solve the problem. It is not the pharmacist's role to provide consultation about the documentation of drugs administered by nurses. Consulting the evening nurses may be helpful, but this is a systems issue for the entire unit and involves every registered nurse administering analgesic medication.

The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught? A. the amount of education the acute MI clients received on the telemetry unit B. the percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity C. the quality of teaching by the nurses who educate the acute MI clients on the telemetry unit D. the clients' perception of the quality of the discharge instructions

B

A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the situation, background, assessment, and recommendation (SBAR) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment? A. prescribing a chest CT scan B. starting oxygen C. providing sedation D. transferring the child to pediatric intensive care

B The infant is experiencing signs and symptoms of respiratory distress indicating the need for oxygen therapy. Sedation will not improve the infant's respiratory distress and would likely cause further respiratory depression. If the infant's respiratory status continues to decline, they may need to be transferred to the pediatric intensive care unit. Oxygen should be the priority as it may improve the infant's respiratory status. A chest CT is not indicated. However, a CXR would be another appropriate recommendation for this infant.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an assessment. The nurse then informs the health care provider and the nursing supervisor about this incident and also completes an incident report. Which actions by the nurse indicates correct knowledge of handling an incident report? A. mentions in the client's report that an incident report was completed B. makes a copy of the incident report to give to the health care provider C. completes a full incident report D. makes a copy of the incident report and places it in the client's records

C An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

The health care provider (HCP) verbally prescribed carboprost tromethamine 0.25 mg intramuscularly stat for a client experiencing a postpartum hemorrhage. The nurse administers the medication but later finds that the HCP has written a prescription for 0.25 mg carboprost tromethamine intravenously stat. How should the nurse respond? A. Ask the charge nurse to discuss the prescription with the HCP. B. Initiate an incident report. C. Wait until the HCP returns to the unit and discuss the situation in person. D. Call the HCP, discuss the prescription, and request a revision if heard correctly.

D

In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? A. orders for diagnostic studies B. orders for respiratory treatments C. orders for dietary changes D. orders for antibiotics

D Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? A. Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. B. Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. C. Ask the staff nurses to form a task force to review and revise discharge policies and procedures. D. Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility.

D

Which prescription is entered correctly on the medical record? A. give 4 U regular insulin IV now B. 60.0 mg ketorolac tromethamine given IM for c/o pain C. fentanyl 50 micrograms given IV every 2 hours as needed for pain greater than 6/10 D. 0.5 mg MS given IM for c/o pain

C Prescriptions should be written clearly to avoid confusion or misinterpretation. Clearly written prescriptions do not use a "trailing" zero (a zero following a decimal point) and do use a "leading" zero (a zero preceding a decimal point). Additionally, the prescribed medication should be written in full and avoid abbreviations of the drug and the dosage, such as "morphine sulfate" (avoiding use of "MS") and "micrograms" instead of "mcg."

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first? A. Continue to give the medication because the client has been taking it for 3 days. B. File an incident report because several other staff members have given the medication to the client. C. Hold the medication and report the information to the physician to ensure client safety. D. Find out whether there are extenuating reasons for giving the drug to this client.

C The nurse should report the information to the physician because the client's safety may be endangered. The nurse shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

The nurse gave the client the wrong medication. It is 2 hours later when the nurse realizes the error. What should the nurse do first? A. Complete an incident report. B. Notify the health care provider (HCP) of the error. C. Assess the client's condition. D. Report the error to the unit manager.

C

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury and notifying the primary care provider, the nurse fills out an incident report. Which of the following is the nurse's NEXT action? A. Give the incident report to thenurse-manager B. Place the incident report on the chart C. Call the family to inform them D. Omit mentioning the fall in the chart

A The incident report should be given to the nurse-manager. The incident report should not be placed on the medical record because it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the medical record. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the HCP should place the call.

The nurse manager overhears comments made between two nurses. The first nurse repeatedly makes comments that focus on the second nurse's skin color and race. The second nurse is observably offended. Which action by the nurse manager to address the behavior of the first nurse would promote a quality practice environment? A. Provide the first nurse with a pamphlet that addresses harassment and discrimination in the workplace. B. Speak to the first nurse, pointing out that the comments constitute harassment and will not be tolerated. C. Use posters and in-service sessions on the unit to help educate the first nurse on racial diversity. D. Wait until the second nurse submits a formal report to the human rights department before doing anything.

B

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving A. O-negative blood to an O-positive client. B. A-positive blood to an A-negative client. C. B-positive blood to an AB-positive client. D. O-positive blood to an A-positive client.

B An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

Which guidelines define and regulate what the nurse may and may not do as a professional? A. facility policies and procedures B. nurse practice act C. state legislature D. standards of care

B Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

The nurse manager has noticed a sharp increase in medication errors associated with intravenous (IV) antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then take which action? A. Document it on their evaluations. B. Ask them to attend in-service training for administration of IV medications. C. Report them to the supervisor. D. Report the incidents to the hospital attorney.

B Identification of causes of medication errors requires in-service education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures. Documenting or reporting the situation would not directly assist the nurses in eliminating errors. Reporting the incidents to the hospital attorney is unnecessary.

The nurse from the postanesthesia care unit (PACU) is transferring a client to an orthopedic unit. Which is the most appropriate way for the nurse in the PACU to communicate the "hand-off-of-care" report with the nurse on the orthopedic unit? A. Give a written report to a transporter who is bringing the client to the receiving nurse. B. Call the nurse on the orthopedic unit and give a verbal report. C. Send an email to the receiving nurse on the orthopedic unit. D. Send the unit clerk from PACU to give the prescription list directly to the nurse on the orthopedic unit.

B The Joint Commission and the Health Council of Canada both mandate interactive handoff communication that allows the opportunity for questioning between the giver and receiver of client information, including up-to-date information regarding the client's care, treatment and services, current condition, and any recent or anticipated changes. Nurses have primary responsibility and accountability for the utilization of all nursing care provided to clients. The nurse retains the right and has the responsibility to refrain from delegating specific activities based on individual client care needs, caregiver expertise, and client care program requirements.

Following notification of two client falls on the unit, a nurse manager decides a formal investigation is necessary and informs the staff. Which statement indicates the primary reason the nurse manager would perform an investigation to determine the causes of the falls? A. "I want to determine exactly what happened and why the two clients fell." B. "I would like to establish the causes and trends related to client falls." C. "I want to identify the environmental factors that contributed to the falls." D. "I would like to know which staff members were on duty when the falls occurred."

B The analysis will identify variations in performance that cause or could cause the clients to fall. It will identify the answer to the question of "How can we prevent this from happening again?" It does not place blame on individuals; rather, it looks at systems and processes. Limiting the focus of the inquiry to the specific clients or staff members does not meet the criteria for root cause analysis, because those foci are too narrow in scope. Similarly, limiting the inquiry to only environmental factors could result in missed data important to the contributing factors for the falls. The nurse examines all potential contributing factors to develop the most helpful investigation.

A home health agency is seeing an increase in the number of clients with GI disorders. How can the staff education coordinator ensure that the staff is knowledgeable about advances in GI care? Select all that apply. A. Ask the staff what their needs are. B. Allow time off for educational programs and conferences. C. Make instructional videos and educational materials available. D. Incorporate biannual competencies. E. Assign nurses who are most comfortable working with GI clients.

B, C, D The goal is to educate the staff and insure competency. Assigning nurses who are most comfortable does not fix the problem on a long-term basis; nor does asking the staff what their needs are. Staff changes and mechanisms need to be in place for continued education.

The nurse notes grapefruit juice on the breakfast tray of a client with type 2 diabetes mellitus who is taking repaglinide. What should the nurse do next? A. Contact the manager of the food and nutrition department. B. Substitute a half grapefruit in place of the grapefruit juice. C. Remove the grapefruit juice from the client's tray, and bring another juice of the client's preference. D. Request that the dietitian discuss the drug-food interaction between repaglinide and grapefruit juice with the client.

C

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? A. notifying the health care provider of the incident and the client's condition B. submitting the incident report to the appropriate hospital administrator C. making a copy of the incident report for the client D. documenting the incident factually in the client's record

C A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the health care provider of the incident and the client's condition.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? A. The facility will report the incident to the state board of nursing for disciplinary action. B. The nurse will be suspended and, possibly, terminated from employment at the facility. C. The incident report will provide a basis for promoting quality care and risk management. D. The incident will be documented in the nurse's personnel file.

C Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension. Some facilities do track the number of errors a nurse or a particular unit makes; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

A client with acute respiratory distress syndrome is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the partial pressure of arterial oxygen PaO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP). What recommendation should the nurse give to the HCP? A. starting a high-protein diet. B. increasing the ventilator rate. C. providing pain medication. D. initiating intravenous sedation.

D The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.

A nurse has made a medication error. Which information is appropriate to include in the incident report? A. the extenuating circumstances involved in the situation B. the client's statement about the incident that occurred C. an interpretation of the likely cause of the incident D. what the nurse saw and did

D The incident report includes only what the nurse saw and did—the objective data. The nurse does not try to interpret the likely cause of the incident, include statements from the client about the incident, or comment on extenuating circumstances.

An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff? A. "If the client needs to be transported, transport personnel need to wear a mask." B. "It is okay to leave the client's room door open to allow for interaction with the staff." C. "When wearing a respirator, it needs to be removed before leaving the client's room." D. "The client needs to be placed in a private, negative air pressure room."

D A client with tuberculosis should be on airborne precautions. This includes using a private, negative air pressure room, transporting the client as little as possible, having the client wear a mask if the client is being transported out of the room, removing the respirator after leaving the client's room, and keeping the client's room door shut.

The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give hand-off reports at which time(s)? Select all that apply. A. when the unit clerk goes to a staff meeting B. when the nurse goes to lunch C. change of nurses D. when new medication prescriptions are written E. change of shift

B, C, E Effective communication is essential when managing client safety and preventing errors. "Hand-off reports" should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transferred to another unit. There does not need to be a hand-off report when the unit clerk leaves the unit or when new medication prescriptions are written.

A client is participating in a cardiac research study in which the client's physician is directly involved. Which statement indicates a need for additional teaching about the client's rights as a research study participant? A. "I may withdraw from the study at any time; but if I do, I won't receive the compensation I was promised." B. "My confidentiality won't be compromised by this study." C. "I'll have to find a new physician if I don't complete this study." D. "I understand that there may be risks associated with this study."

C The client stating a requirement to find a new physician if the client does not participate in the study indicates a need for additional teaching. Whether the client participates in this study should not influence the relationship with the physician. The client has the right to withdraw from a study at any time without penalty. All information provided by the client is kept confidential and used only by members of the study team for scientific purposes. The client must be informed of all risks associated with study participation.

A client with cholecystitis has severe pain unrelieved by ibuprofen. The client feels nauseated. The nurse obtains the following vital signs: temperature 101.1°F (38.4°C); pulse 114 bpm; respirations 22 breaths/min; and blood pressure 142/90 mm Hg. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what should the nurse recommend to the health care provider for this client? A. a medication for elevated blood pressure B. a medication for increased temperature C. a medication for feelings of nausea D. a medication for severe pain

D The client has severe pain, and the nurse should contact the health care provider for pain medication. An opioid such as morphine is usually prescribed intravenously to manage severe pain. Elevation of the heart rate and blood pressure is likely due to the pain. The pain medication may also relieve the nausea.

A healthcare agency has set a plan to apply for accreditation. A nurse on the accreditation committee has been assigned to audit clients' medical records for appropriate documentation. What information would the nurse assess in the audit? A. evidence of home care and nursing follow-up for 6 weeks following discharge B. evidence that nurses have set goals for improving future practice C. evidence of self-reflection from nursing and other care providers about the quality of their care D. evidence that nursing interventions have been evaluated in terms of the client's response

D The medical record serves multiple purposes, including a role in accreditation. Accreditors look for evidence of evaluation following interventions. The medical record is not the correct venue for nurses' self-reflection or personal goal-setting. Many clients do not require community-based follow-up after they have been discharged.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? A. Stop the transfusion, notify the blood bank, and administer antihistamines. B. Slow the transfusion and monitor the client's vital signs. C. Assess the temperature, blood pressure, and check for blood in the urine. Then stop the transfusion. D. Stop the transfusion, infuse normal saline solution, and call the physician.

D When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions should not be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.